Distal Extent of Surgery for Acute Type A Aortic Dissection

Abstract

Acute type A aortic dissection (TAAD) is a complex disease associated with extremely high morbidity and mortality for which we advocate a coordinated, protocol-driven system of care delivery that begins at patient diagnosis and continues throughout and beyond aortic reconstruction. Essential components of TAAD repair include prompt restoration of true lumen blood flow with obliteration of the false lumen flow, resection of the primary tear sites, restoration of valvular competency, and elimination of any organ malperfusion. This article focuses specifically on extent of repair of the aortic arch and explains our protocols regarding cannulation location and technique, cerebral and distal organ protection strategy, management of the brachiocephalic vessels, and extent of distal aortic reconstruction. We describe an operative strategy for TAAD repair that includes (1) continuous neurocerebral monitoring in all cases, (2) uninterrupted antegrade and/or retrograde cerebral perfusion (depending upon extent of arch repair) during open arch reconstruction, (3) aortic arch replacement technique with or without brachiocephalic vessel replacement using a custom trifurcate graft, and (4) descending aortic stabilization with or without the use of an elephant or frozen elephant trunk (distal stent graft). Our protocol for extent of aortic arch and brachiocephalic reconstruction has been standardized and is predicated on distinct pathoanatomic findings and/or cerebral malperfusion that are outlined. Operative Techniques in Thoracic and Cardiovasculary Surgery 24:82À102

Hemiarch replacement with aortic root preservation for acute type A aortic dissection

“…TAAD remains a true surgical emergency requiring fast and complex surgical decision making and is traditionally associated with high morbidity and mortality even in experienced hands. Proper management of patients with TAAD starts with prompt diagnosis based on CT angiogram, rapid transfer to the operating room or to a center experienced in the operative management of these patients with the goal of (I) expeditious restoration of true lumen blood flow with obliteration of false lumen flow to eliminate any malperfusion, (II) resection of the primary tear site(s) and (III) restoration of valvular competency; all while ensuring optimal neurocerebral and distal organ protection via core cooling and antegrade (ACP) and/ or RCP during circulatory arrest (6). In our experience, RCP is utilized during shorter periods of circulatory arrest (hemiarch replacement) while ACP is utilized for total arch reconstruction (7).…”

“…Only isolated studies have described comparable operative mortality for patients undergoing hemiarch vs. total arch reconstruction (16). At our institution, we follow an algorithmic approach based on imaging and intraoperative findings (6,14). The need for aortic arch repair (i.e., TAR) is predicated on the presence of one or more of four key findings ( 6): (I) presence of an aortic arch aneurysm, (II) primary, secondary or reentry tear in the arch or proximal descending aorta, (III) circumferential dissection of the aortic arch and/or (IV) carotid dissection causing cerebral malperfusion.…”

Commentary: Location, location, location—proximal right subclavian cannulation for thoracic aortic surgery

“…However, central aortic cannulation has been shown, even in TAAD, to be a rapid and reliable technique that does not require additional incisions. 5 The technique allows for both ACP and retrograde Proximal right subclavian arterial cannulation via Seldinger technique offers the benefits of expeditious subclavian arterial cannulation with minimal risks. cerebral perfusion, which may be advantageous in certain cases.…”

“…cerebral perfusion, which may be advantageous in certain cases. [5][6][7] Regardless of arterial cannulation strategy, surgeons should be encouraged to develop a standardized approach to cannulation that is rapid, reliable, and safe for patients and continue to adapt based on updated evidence.…”

Making hay while the sun shines: Do outcomes after surgery for acute type A aortic dissection depend on when it is performed?

“…Advances have been related to operative strategy (e.g., cannulation and cerebral perfusion); decision-making (e.g., the optimal extent of distal and proximal repair); and institutional (e.g., improved referral networks to aortic centers of excellence). [8][9][10][11][12][13][14][15][16][17][18] However, prima facie, performing ATAAD surgery "out of hours" represents a clear opportunity for improving the safety and quality of these highrisk operations.…”